Modifiable risk factors for falls among older adults with advanced cancer

328

Background: Older adults with cancer are more likely to fall than those without cancer, but the factors driving this increased risk are not fully understood. Falls may lead to injury, dependence, hospitalization, and death. Given the interventions available to reduce fall risk, identifying risk factors amenable to intervention for older adults with cancer is critical to provide targeted care and improve health outcomes. Methods: To examine factors associated with patient-reported falls within a 6 month follow up period, we analyzed data previously collected in a nationwide cluster randomized trial (ClinicalTrials.gov: NCT02107443; PI: Mohile, NCORP UG1CA189961). Patients were eligible if age ≥70, stage III/IV solid tumor or lymphoma with palliative treatment intent, and ≥1 geriatric assessment impairment (GA). A GA summary with tailored recommendations was given to oncologists in practices randomized to the intervention, but not usual care. We combined intervention and usual care groups and evaluated baseline risk factors for falls over a 6 month follow up including: prior falls, fear of falling (FOF), activity limitation due to FOF, activities of daily living, Short Physical Performance Battery, Timed Up and Go (TUG), Older Americans Resources Survey (physical health scale), cognition, polypharmacy, potentially inappropriate medications (PIM), and neurotoxic treatment agents. Incidence rate ratios (IRR) were estimated using generalized linear mixed models controlling for the study arm and practice site. Fully adjusted multivariable models were built for factors associated with follow up falls (p≤0.15) in bivariate. Results: Of 541 patients (mean age: 77, SD: 5.27), 140 (26%) patients had prior falls in the past 6 months. Over 6 months of follow up 467 (86%) had falls data for ≥ 1 follow up timepoint and 344 (64%) had complete follow up. Of those contributing any follow up data 103 patients (22%) reported at least one fall. In adjusted models prior falls, impaired TUG, and number of PIM were associated with higher incidence of falls over 6 months (see Table). Conclusions: Prior falls, TUG, and PIM are prospectively associated with falls among older adults with advanced cancer. These factors are feasible to assess and amenable to interventions such as rehabilitation or deprescribing. Future studies focused on implementation of fall risk reduction in the oncology setting are needed to determine the most effective ways to reduce fall risk in this vulnerable population. Clinical trial information: NCT02107443. [Table: see text]

Myopenia and mechanisms of toxicity in older adults with colorectal cancer (CRC): The M&M study (WF-1806)

TPS3640

Background: CRC is the 2nd most common cause of cancer death in the US, and nearly 60% of CRC cases occur among older adults. There is a critical unmet need to understand the underlying cause(s) of observed variability in chemotherapy toxicity (chemotoxicity) outcomes to minimize adverse outcomes and appropriately personalize therapy for older adults. Low muscle mass, known as myopenia, is prevalent in older adults with CRC (̃60%) and is associated with chemotoxicity and decreased overall survival (OS). However, little is known about trajectories of myopenia and underlying mechanisms of increased toxicities and decreased survival in myopenic patients. We address these gaps in a prospective cohort study, with the central goal of examining the role of myopenia in chemotoxicity in older adults with metastatic CRC undergoing 5-Fluouracil (5FU) based chemotherapy, and to explore the mediating influence of germline genetic variants and pharmacokinetics (PKs) in the association between myopenia and chemotherapy toxicity. Methods: This prospective cohort study is accruing through the Wake Forest NCI Community Oncology Research Program Research Base (WF NCORP) and funded by the NCI grants 2UG1CA189824 and K08CA234225. The study examines the impact of myopenia on chemotoxicity and OS in older adults with newly diagnosed metastatic CRC planning to receive systemic 5FU-based chemotherapy (either as monotherapy or in combination with oxaliplatin and/or irinotecan +/- biologics) (NCT03998202). All patients undergo the Cancer & Aging Resilience Evaluation and Life-Space Evaluation at baseline, 3 and 6 months. Standard of care Computed Tomography (CT) images will be obtained to assess muscle measures (skeletal muscle area/density) at the L3 cross-section. The primary outcome is grades 3 to 5 chemotoxicity measured up to 6 months after initiation of chemotherapy using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 5.0. We will assess the association of baseline myopenia and trajectories of myopenia with severe chemotherapy toxicities. Secondary outcome measures include OS at 1 year and chemotoxicities using the Patient Reported Outcomes (PRO) version of the CTCAE. The study also explores the mediating/moderating influence of genetic variation and altered PKs (n = 60) in the association between myopenia and chemotherapy toxicity. To date, the study has accrued 73 of the 300 targeted patients from 110 NCORP practices. Clinical trial information: NCT03998202.

Early quality of life (QOL) and symptom analysis from the DREAMseq phase III randomized control trial of combination immunotherapy versus targeted therapy in patients (pts) with BRAF-mutant metastatic melanoma (MM) (ECOG-ACRIN EA6134)

9559

Background: Combinations of either immune checkpoint inhibitors (anti-PD-1/anti-CTLA-4) or BRAF/MEK-targeted therapies have shown significant clinical benefit in pts with BRAFV600 mutant MM. Until recently, little prospective data existed to guide the choice of initial therapy or sequence. Results of the DREAMseq Trial showed that the treatment sequence beginning with nivolumab/ipilimumab (Nivo/Ipi) immunotherapy produced a clinically meaningful 20% improvement in 2-year overall survival (OS) compared to the sequence beginning with dabrafenib/trametinib (Dab/Tram) targeted therapy. The OS and progression-free survival (PFS) curves were biphasic crossing at 10 and 6 months, respectively. Our aim is to characterize QOL trends within and between the initial therapies through 24 weeks (wks). Methods: 265 pts were randomly assigned to Nivo/Ipi for up to 12 wks then Nivo alone (Arm A) or Dab/Tram continuously (Arm B) and at disease progression (PD) received the alternate therapy. QOL was assessed by the PROMIS Profile 29 at baseline, wk 12 (end of cycle (C) 2), and wk 24 (end of C4). Wilcoxon Signed Rank test was used to examine changes over time within treatment arms. OS was estimated by Kaplan-Meier method to compare between pts who stopped treatment for toxicity on Arm A by C2 and who continued on Arm A therapy to C4. A complete case analysis compared QOL domain means for (C2) vs. (C4). Pt-reported adverse events were also collected. Results: Baseline completion rates for the PROMIS-29 for Arm A (n = 108, 81.2%) and Arm B (n = 117, 88.6%) and decreased to 28.6% and 53.8%, respectively at C4. Through C4, the principal reasons for dropout were toxicity (35.2% for Arm A and 11.9% for Arm B) and PD (26.1% for Arm A and 18.6% for Arm B). From Baseline to C2: Arm B reported statistically significant improvements in Pain Interference (-3.45, P = 0.007), Sleep (-2.11, P = 0.014), and Anxiety (-3.74, P < 0.001). By C4, these early differences had dissipated (mean diff. = 0.73 – 1.73, all p = NS). For pts remaining on treatment to C4 (n = 157), a complete case analysis indicates no significant QOL differences between C2 vs C4. Pts stopping for toxicity on Arm A after C2 had similar 2-yr OS to pts who continued on Arm A to C4. QOL at C2 (Arm A: stopping for toxicity vs. on treatment) were meaningful, but underpowered (Physical Health (PH) mean difference = -3.5, p = 0.18). Conclusions: Over the first 12 wks, Dab/Tram is associated with significant improvement in overall function and less disturbance in in sleep, pain, physical function, and PH than Nivo/Ipi as expected by PFS curves and toxicity profiles. These differences dissipate by 24 wks when Arm A therapy has switched to Nivo alone and PFS curves cross. Early QOL and treatment cessation due to Nivo/Ipi toxicity was not associated with differences in 2-yr OS. Clinical trial information: NCT02224781.

DREAMseq (Doublet, Randomized Evaluation in Advanced Melanoma Sequencing): A phase III trial—ECOG-ACRIN EA6134

356154

Background: Combinations of immune checkpoint inhibitors (CPI) blocking PD-1 and CTLA-4 or BRAF/MEK inhibitors have both shown significant antitumor efficacy and overall survival (OS) benefit in patients (pts) with BRAFV600-mutant metastatic melanoma (MM), leading to broad regulatory approval. Little prospective data exists to guide the choice of one over the other as initial therapy or the preferred treatment sequence in this population. The DREAMseq Trial was designed to compare the efficacy and toxicity of the sequence of nivolumab/ipilimumab (N/I) followed by dabrafenib/trametinib (D/T) to the converse sequence. Methods: Eligible pts with treatment-naive BRAFV600-mutant MM were stratified by ECOG Performance Status (PS) 0 or 1 and LDH level and randomized 1:1 to receive Step 1 with either N/I (Arm A) or D/T (Arm B) and at disease progression (PD) were enrolled in Step 2 receiving the alternate therapy, D/T (Arm C) or N/I (Arm D), respectively. Pts received N (1mg/kg)/I (3 mg/kg) q3 wks x 4 doses followed by N 240 IV q2 wks for up to 72 wks (Arms A and D) or D 150 mg po BID and T 2 mg po qD until PD (Arms B and C). In 2019, investigators were given the option to use alternate induction dosing of N (3mg/kg)/I (1 mg/kg) q3 wks x 4 doses for Arms A and D. Cycles were every 6 wks and imaging was obtained at baseline and q12 wks on each arm. Primary endpoint was 2-year OS. At the 4th Interim Analysis with 59% of pts being 2 yrs from enrollment, the DSMC and NCI CTEP recommended halting accrual and releasing the data. Results: Beginning 7/2015, 265 out of a proposed 300 pts were enrolled (133 Arm A and 132 Arm B). Median age was 61 (25-85) and 63% were male. Demographics for Arm A and B were balanced with 67% PS 0 and 60% with normal LDH. As of 7/16/21, at a median follow-up of 27.7 mos, 27 pts had switched to Arm C and 46 to Arm D. Overall Grade 3+ toxicity was 60% in Arm A and 52% in Arm B. Grade 5 treatment-related AEs included 2 on Arm A and 1 on Arm C. ORR to date is: Arm A 46% (52/113), Arm B 43% (49/114), Arm C 48% (11/23) and Arm D 30% (8/27). 37/42 assessed pts in Arm A and 19/37 in Arm B remain in response. Median DOR: Arm A- Not reached; Arm B-12.7 mos (95% CI: 8.2, -) (p <0.001). There were 100 deaths (Arm A to C- 38/Arm B to D- 62). 2-yr OS rate for those starting with Arm A was 72% (95% CI: 62-81%) and for Arm B 52% (95% CI: 42-62%) (log-rank p= 0.0095). PFS showed a trend in favor of Arm A (log-rank p=0.054). Both the PFS and OS curves show a biphasic pattern with Arm B being above Arm A until 6 and 10 mos, respectively. For the 115 pts with documented progression on Step 1 (Arm A-44/Arm B-71), 60 (52%) had registered for Step 2. The principal reason for not enrolling on Step 2 was death from PD within 6 mos (Arm A:15/23; Arm B: 25/32). Conclusions: For pts with advanced BRAFV600-mutant MM, the treatment sequence beginning with the CPI combination of N/I resulted in superior OS, which became evident at 10 mos, with longer Step 1 DOR and more ongoing responses than the treatment sequence beginning with D/T. Clinical trial information: NCT02224781.

Hope-enhancement workshops in the SWOG Cancer Research Network: Feasibility of an online intervention

210

Background: Research shows that healthcare professionals’ personal hopefulness is associated with burnout and life satisfaction, highlighting the value of hope-enhancement interventions. Feldman and Dreher developed a single-session hope intervention, but this has been used rarely with oncology professionals, and only in in-person format (Shah, Ferguson, Corn et al.). Given SWOG Cancer Research Network’s commitment to assessing hope-enhancement approaches and the need for online interventions given COVID-19, we report a feasibility study of a virtual hope workshop in SWOG members. Methods: The workshop was a single 2-hour session delivered live via Zoom to 6-8 participants at a time. The workshop comprises 3 components: A brief lecture on hope and two exercises—a “hope mapping” exercise (aided by a smartphone app created for the workshop) and a hope visualization exercise—both designed to build hope for a life goal of each participant’s choosing. 29 SWOG members participated. A link to post-workshop measures was sent to participants, which they were given a week to complete. Measures included Thanarajasingamet al’s 5-item Was-it-Worth-it (WIWI) measure; Kirkpatrick’s 4-item Training Evaluation Model (TEM; reaction, learning, behavior, results); and an item assessing the degree to which participants believe concepts from the workshop should be integrated into SWOG studies. Results: In all, 25 participants (86%) completed measures. Participants were physicians (n = 8), nurses (n = 4), patient advocates (n = 3), research staff (n = 3), and others (n = 7); mostly female (n = 17), mostly white (n = 18), with a mean age of 55.5 (SD = 13.95). Results for the WIWI items are as follows: “Was it worthwhile to participate in the Hope Workshop?” (23 Yes, 2 No/Undecided/Missing Answer); “If you had to do over, would you participate in the Hope Workshop again?” (22 Yes, 3 No/Undecided/Missing Answer); “Would you recommend participating in the Hope Workshop to others?” (22 Yes, 3 No/Undecided/Missing Answer). Two additional items on the WIWI asked participants to rate on a 3-point scale the degree to which they believe their quality of life had increased due to the workshop (M = 2.52, SD =.51) and their overall experience in the workshop (M = 2.70, SD =.64). Ratings for Kirkpatrick’s TEM items likewise were high, ranging from 6.91 (SD = 1.31) to 7.70 (SD =.70) on an 8-point scale. Finally, participants gave a mean rating of 4.44 (SD =.59) on a 5-point scale to the item “To what degree do you believe it may be useful to integrate concepts from this workshop into SWOG trials/studies?” Conclusions: It is feasible to implement hope-enhancement workshops in an online platform that includes a smartphone app. Data obtained from two validated tools (WIWI instrument and Kirkpatrick’s TEM) attest to an array of positive outcomes. Participants also overwhelmingly advocated integrating hope concepts into SWOG’s research.

Development and validation of the self-efficacy for medical communication scale

12124

Background: Most studies of clinician-patient communication use scales created ad hoc with unknown validity. To provide a standard measure for future studies, we developed and validated a new scale of clinician-reported skills in communicating difficult news: the Self-Efficacy for Medical Communication (SEMC) scale. Methods: Using evidence-based scale development guidelines, we created 16 items sampling a range of communication skills, including “Disclose difficult news in manageable chunks, so the patient is not overwhelmed,” and “Determine how to present information based on the patient’s emotional state.” Items are rated on Likert scales from 1 ( cannot do at all) to 10 ( highly certain can do). We constructed two forms—one assessing communication with patients and one with family—using identical items but replacing “patient” with “family/caregiver.” We examined the convergent and discriminant validity of the SEMC (correlations with similar and dissimilar measures) as well as its reliability and factor structure. A total of 221 clinicians working in oncology settings (physicians, nurses, medical students) completed measures online. Convergent measures included medical communication items from past studies; the Self-Perceived Communication Competence Scale to measure communication ability outside the medical realm; and the General Self-Efficacy and Occupational Self-Efficacy scales to measure overall self-efficacy/confidence. Discriminant measures included the Ten Item Personality Inventory to measure personality factors; the Maslach Burnout Inventory to measure job burnout; and the Satisfaction with Life Scale to measure well-being. Finally, the Marlowe-Crowne Social Desirability (MCSD) scale measured motivation to “look good” in responding to survey questions. Results: Mean scores were similar for the patient (126.36) and family (127.09) forms (max score 160), both with excellent reliability ( alphas =.94,.96, respectively). Because these forms were almost perfectly correlated ( r =.95, p <.001), we used only the patient form in subsequent analyses. Factor analysis demonstrated that the SEMC measures a unitary construct ( eigenvalue = 9.0). Its mean correlation was higher with convergent ( r =.46) than discriminant measures ( r =.22), supporting its validity. Moreover, its correlation with the MCSD was small ( r =.28) and no larger than between the MCSD and other measures, indicating minimal social-desirability effects. Finally, no differences emerged for gender or profession; higher scores did correlate with age ( r =.29, p <.001) and years working in oncology ( r =.18, p =.01). Conclusions: Our findings support the SEMC’s validity and reliability. Scores on the patient and family forms were similar, indicating that either may be used. The SEMC provides a useful tool for measuring clinician-rated communication skills in future research, ultimately allowing standardization across studies.

A hopefulness survey of SWOG members: Relationships among hope, job stress, and burnout

185

Background: Hope is a cognitive, goal-directed phenomenon that is measurable. It is “a cognitive set that is based on a reciprocally-derived sense of successful agency (goal-directed determination) and pathways (planning to meet goals).” Although hope has been explored in patients, few studies have investigated hope in physicians and other healthcare providers. Low hope has been shown to predict work burnout in other professions. This survey in the SWOG Cancer Research Network tests the relationships among hope, work stress, burnout, and general satisfaction with life. Methods: SWOG members randomly selected and invited to participate by email linked to a 10-minute online survey consisting of the following: The Adult Hope Scale, Satisfaction with Life Scale, demographic questionnaire, and items assessing burnout, work stress, and general social support. Of 1000 invitees, 226 responded to the survey, including physicians ( n = 77) and RNs ( n = 46). Results: On average, respondents reported relatively high work stress ( M = 3.59 out of 5). Levels of work stress were positively associated with burnout ( r = .58, p < .001), but not with general satisfaction with life ( r = .11, p = .08). Hope levels were negatively associated with burnout ( r = -.21, p = .003) and positively associated with satisfaction with life ( r = .58, p < .001). Consistent with past research showing that people with greater availability of general social support suffer from lower rates of burnout and experience higher levels of psychological well-being, we found that social support was negatively associated with burnout ( r = -.18, p = .007) and positively associated with life satisfaction ( r = .38, p < .001). In addition, we tested a meditational model using Hayes’ bootstrapping approach via the PROCESS macro in SPSS. In this model, hope partially mediated the relationships between social support and both burnout and life satisfaction. In the model, job stress also predicted burnout, but, as in the previous correlational analysis, had no relationship with general life satisfaction. Conclusions: Our cross-sectional results suggest that hope may mitigate the effects of burnout. Our data indicate that the particular combination of social support and hope may prove helpful for reducing job burnout and increasing general satisfaction with life. Single-session hope-enhancement workshops that incorporate both of these elements have been shown to increase hope and psychological well-being in non-medical populations. Such interventions for healthcare professionals warrant further study.

Relationship between clinical work intensity, hopefulness and well-being among medical oncologists

46

Background: Oncology providers’ well-being particularly concerns administrators, as projections suggest a shortfall in number of providers available to care for an increasing cancer survivor population. This pilot study solicited medical oncologists’ ratings on Clinical Work Intensity (CWI), well-being, and hope constructs: agency (goal-directed determination) and pathways (planning ways to meet goals), to understand relationships between clinical work intensity, hopefulness and well-being. Methods: Eleven providers (8 = MD and 3 = NP) practicing in three distinct community-based oncology sites completed the CWI measure, NASA-TLX, immediately following an office visit, for 20 separate visits. Each provider also completed one well-being index and one Adult Hope Scale that included agency and pathways subscales after the 20 visits. Lower well-being scores indicated higher well-being; higher hope scores indicated greater hopefulness. Results: Clinical work intensity positively correlates with well-being (Spearman rho = 0.16; p = 0.02). Clinical work intensity was inversely related to the total hopefulness score (Spearman rho = -0.25; p < 0.001) and Hope construct subcomponents of perceived pathway to goal achievement (Spearman rho = -0.24; p < 0.001), and determination to meet goals (agency) (Spearman rho = -0.15; p < 0.001). Favorable provider well-being was also related to agency (Spearman rho = -0.71; p < 0.0001). Conclusions: Higher provider-rated work intensity in sampled clinical encounters correlates, albeit weakly, with less favorable well-being scores. Higher CWI also correlates with lower hope scale scores. Thus, providers’ perceptions of their mental workload in clinical care are potentially related to their sense of well-being and hopefulness. Results also suggest provider determination to meet goals (agency) is also reflected in sense of well-being. These findings support further investigation using larger, more diverse samples to affirm observed relationships. Future research may also elucidate intervention targets through which to abate provider distress portending burnout. Insights gleaned from future work may inform improvements to the work life of oncology care providers.

Cumulative incidence of financial hardship in metastatic colorectal cancer (mCRC) patients (pts): Primary endpoint results for SWOG S1417CD

137

Background: Despite evidence that rising cancer care costs contribute to “financial toxicity” in cancer pts, no studies, to our knowledge, have prospectively assessed the financial impact of cancer diagnosis (dx) using both self-reported and objective financial measures. S1417CD, led by the SWOG Cancer Research Network and conducted in the NCI Community Oncology Research Program (NCORP), was the first national prospective cohort study to evaluate time-to-first evidence of major financial hardship (MFH) in pts with newly diagnosed mCRC. We present results of the primary endpoint analysis. Methods: Pts age ≥ 18 within 120 days of mCRC dx receiving systemic treatment completed surveys every 3 months (mo) for 12 mo. MFH was defined as ≥ 1 occurrence of self-reported increase in debt, new loans, selling home, refinancing home, or ≥ 20% income decline during the 12 mo study period. Cumulative incidence (CI) of MFH was estimated to account for competing risk of death. Multivariate logistic regression was used to evaluate the association between pt characteristics with development of MFH. Results: 380 pts (median age 59.9) across 126 clinic sites were enrolled. Most pts were white (78%), male (61%), and insured (98%), with annual income ≤ $50,000 (56%). Cumulative incidence of MFH at 12 mo was 71.5% (95% CI: 65.9%-76.3%), with 24.6%, 52.4%, and 61.8% at 3, 6, and 9 mo; 104 (41%) pts reported ≥ 2 elements of MFH. Age, race, marital status, employment, and annual income (≤ vs. > $50K) were not significantly associated with MFH. In a post hoc analysis, income <$100,000 and total assets <$100,000 were both adversely associated with MFH. Each increase in number of these 2 risk factors from 0 to 1 and 1 to 2 was associated with a 49% increased risk of MFH (p<.001). Conclusions: In a national sample of mCRC pts on systemic tx, financial hardship, most commonly in the form of increased debt, accumulates progressively over time. Nearly 3 out of 4 pts experiencing MFH at 12 mo despite access to health insurance coverage. These findings underscore the need for clinic and policy solutions such as early financial navigation and elimination of cost sharing to protect pts from financial devastation as they continue with tx. [Table: see text]

The association of patient fatigue and outcomes in advanced cancer: An analysis of four SWOG treatment trials

140

Background: Prior studies have suggested that patient-reported outcomes may be associated with cancer outcomes. We evaluated the association between clinically significant fatigue (CSF) and adverse events (AEs), quality of life (QOL), and overall survival (OS) during cancer treatment. Methods: Four phase II or III chemotherapy trials, two each in advanced non-small cell lung cancer (NSCLC) and advanced hormone-refractory prostate cancer (HRPC), were used to compare patients with or without baseline CSF. Baseline CSF was defined as a rating of 2 or greater on the FACT fatigue survey question or an EORTC QLQ-C30 fatigue symptom score of 50% or greater. Change in QOL from baseline, AE rates, and survival were compared according to baseline CSF with linear regression models, equality of proportions chi-squared tests, and Kaplan-Meier survival estimates and Cox regression models, respectively, separately for each trial. Results: Of 1,994 participants, 1,907 had complete baseline QOL survey data, with 52% reporting CSF at baseline. Baseline CSF was associated with an increased incidence of grade 3-5 constitutional (16.5% vs 9.4%, p = 0.002 and 13.9% vs 6.3%, p = 0.002) and neurological (11.7% vs 6.1%, p = 0.006 and 9.0% vs 3.9%, p = 0.01) AEs, respectively, in two studies of advanced HRPC. Overall, patients with baseline CSF had significantly lower baseline QOL across all four domains (p < 0.01). Across all four studies, baseline CSF was associated with higher mortality rates, with adjusted hazard ratios (95% confidence interval, p-value): 1.34 (1.14, 1.57, p < .001) and 1.30 (1.02, 1.66, p = 0.03) in NSCLC studies, 1.49 (0.95, 2.35, p = 0.09) and 1.53 (1.12, 2.11, p = 0.008) in HRPC studies. Conclusions: Oncology trial participants with baseline CSF had significantly lower baseline QOL, experienced more adverse events and had poorer survival compared to participants without CSF. We have confirmed previous work indicating that fatigue is an important baseline stratification factor that should be considered in all oncology treatment trials. Consistent with other research, our results indicate that fatigue should be measured and ameliorated wherever possible among advanced cancer patients.

The effect of sonidegib (LDE225) on the pharmacokinetics of bupropion and warfarin in patients with advanced solid tumours

AIMS

We evaluated the potential effect of sonidegib at an oral dose of 800 mg once daily (QD) on the pharmacokinetics (PK) of the probe drugs warfarin (CYP2C9) and bupropion (CYP2B6).

METHODS

This was a multicentre, open-label study to evaluate the effect of sonidegib on the PK of the probe drugs warfarin and bupropion in patients with advanced solid tumours. Cohort 1 patients received a single warfarin 15-mg dose on Day 1 of the run-in period and on Cycle 2 Day 22 (C2D22) of sonidegib administration. Cohort 2 patients received a single bupropion 75-mg dose on Day 1 of run-in period and on C2D22 of sonidegib administration. Sonidegib 800 mg QD oral dosing began on Cycle 1 Day 1 of a 28-day cycle after the run-in period in both cohorts.

RESULTS

The geometric means ratios [90% confidence interval] for (S)-warfarin with and without sonidegib were: area under the concentration-time curve from time 0 to infinity (AUC_inf ) 1.15 [1.07, 1.24] and maximum plasma concentration (C_max ) 0.88 [0.81, 0.97]; and for (R)-warfarin were: AUC_inf 1.10 [0.98, 1.24] and C_max 0.93 [0.87, 1.0]. The geometric means ratios [90% confidence interval] of bupropion with and without sonidegib were: AUC_inf 1.10 [0.99, 1.23] and C_max 1.16 [0.95, 1.42]. Sonidegib 800 mg had a safety profile that was similar to that of lower dose sonidegib 200 mg and was unaffected by single doses of the probe drugs.

CONCLUSIONS

Sonidegib dosed orally at 800 mg QD (higher than the Food and Drug Administration-approved dose) did not impact the PK or pharmacodynamics of warfarin (CYP2C9 probe substrate) or the PK of bupropion (CYP2B6 probe substrate).

Feasibility of a digital medicine program in optimizing opioid pain control in cancer patients (SWOG S1916)

TPS12126

Background: The undertreatment of pain in patients with advanced or metastatic cancer is well described in cancer research. Overcoming barriers that prevent successful use of opioid analgesics for cancer pain requires a clear understanding of how individuals use oral medications at home. The Proteus Discover is a digital medicine program (DMP) consisting of an FDA-approved ingestible sensor made of dietary minerals co-encapsulated with patients’ medications, a wearable sensor patch, and a mobile device app that enables patients to electronically transmit their medication adherence patterns. Use of the DMP has demonstrated improved clinical outcomes vs. usual care in patients with diabetes and hypertension, shown superiority over directly-observed therapy in tuberculosis and has been studied in the treatment of patients with hepatitis C, HIV, cancer and severe mental illness, but it has not been previously studied with opioids or in monitoring cancer-related pain. Methods: We are conducting a multicenter pilot study at SWOG NCORP sites to test the feasibility of using the DMP to monitor opioid use in the treatment of metastatic cancer pain. Eligible patients must have a diagnosis of metastatic cancer, have a baseline Brief Pain Inventory worst pain score of ≥3, be deemed by their physician to need initiation or up-titration of oxycodone-acetaminophen for pain control, and be able to read English. Primary outcomes include: (1) study accrual of 60 patients within six months of study activation at all participating sites; (2) patient retention defined as ≥50 patients completing the study, and; (3) adherence to the DMP defined as ≥66% of patients wearing the sensor patch for ≥28 days of the 42-day observation period. Secondary outcomes include change in Brief Pain Inventory pain scores, opioid medication consumption, number of safety alert triggers for high consumption, hospital or emergency room visits for pain, activity levels, and frequency of changes to the pain control regimen. The study will enroll patients at six sites; the first patient was enrolled on 1/20/2020. If successful, this study will inform design of a randomized controlled trial of the DMP vs. usual care in optimizing medication utilization and controlling cancer-related pain. Clinical trial information: NCT04194528 .

Cumulative incidence of financial hardship in metastatic colorectal cancer patients: Primary endpoint results for SWOG S1417CD

7010

Background: Despite evidence that rising cancer care costs are contributing to “financial toxicity” in cancer pts, no studies, to our knowledge, have prospectively assessed the financial impact of cancer diagnosis (dx) using both self-reported and objective financial measures. S1417CD, led by the SWOG Cancer Research Network and conducted in the NCI Community Oncology Research Program (NCORP), was the first national prospective cohort study to evaluate time-to-first evidence of major financial hardship (MFH) in pts with newly diagnosed mCRC. We present results of the primary endpoint analysis. Methods: Pts age ≥ 18 within 120 days of mCRC dx receiving systemic treatment completed surveys every 3 months (mo) for 12 mo. MFH was defined as ≥ 1 occurrence of self-reported increase in debt, new loans, selling home, refinancing home, or ≥ 20% income decline during the 12 mo study period. Cumulative incidence (CI) of MFH was estimated to account for competing risk of death. Additional endpoints, not reported here, included quality of life, caregiver strain, and changes in credit status over 12 mo. Results: In total, 380 pts (median age 59.9) across 126 clinic sites were enrolled, with 377 eligible and evaluable for the primary endpoint (reached 12 mo assessment, death, or MFH endpoint); complete data were available for 92% of pts as of Jan 23, 2020. Most pts were white (78%), male (61%), and insured (98%), with annual income ≤ $50,000 (56%). Cumulative incidence of MFH at 12 mo was 71.5% (95% CI: 65.9%-76.3%), with 24.6%, 52.4%, and 61.8% at 3, 6, and 9 mo. The dominant components of MFH were new debt (12-mo CI, 56.7%) and >20% decline in income (26.7%); 104 (41%) pts reported ≥ 2 elements of MFH. In a secondary analysis excluding new debt, 12 mo cumulative incidence of MFH was 42.9% (95% CI: 37.2%-48.5%), with 10.3%, 24.4%, and 31.9% at 3, 6, and 9 mo. Conclusions: In a national sample of mCRC pts on systemic tx, financial hardship, most commonly in the form of increased debt, accumulates progressively over time. Nearly 3 out of 4 pts experiencing MFH at 12 mo despite access to health insurance coverage. These findings underscore the need for clinic and policy solutions such as early financial navigation and elimination of cost sharing to protect pts from financial devastation as they continue with tx. Clinical trial information: NCI-2015-01885 . [Table: see text]

Design and accrual of S1417CD: Development of a prospective financial impact assessment tool in patients with metastatic colorectal cancer (mCRC)

TPS6652

Background: Few studies have assessed the financial impact of cancer diagnosis (dx) in diverse patients (pts) and caregivers (cgs) using objective and standard financial measures. S1417CD, led by the SWOG Cancer Research Network, is the first prospective cohort study assessing financial outcomes to be conducted in the NCI Community Oncology Research Program (NCORP). We present our experience with design and accrual. Methods: Pts age ≥ 18 within 120 days of mCRC dx were considered eligible and asked to identify a caregiver (cg) who could participate concurrently. The primary endpoint is incidence of treatment-related financial hardship, defined as ≥ 1 of the following: debt accrual, selling/refinancing home, ≥ 20% income decline, or borrowing money. Measures include 1) pt and cg surveys (baseline (BL), 3, 6, 9 and 12 months (mo)) assessing out-of-pocket spending, financial impacts, cg burden, and quality of life and 2) pt credit reports (BL, 6, and 12 mo). Linkage to records from TransUnion, a national credit agency, required pt social security number (SSN) and processes for batched credit report transfer via secure web portal. The accrual goal was n = 374 pts in 3 years. The study activated on Apr 1, 2016 and closed on Feb 1, 2019 after reaching its accrual goal. A total of 380 pts (median age 59.7 years) and 155 cgs enrolled (41% cg participation). Enrollment steadily increased during the study period; 56% enrolled in the last 12 mo. Credit data were not obtainable for 76 (20%) pts due to early death, lack of credit, or inability to match records. S1417CD, the first cooperative group led study assessing financial outcomes in the community setting, completed enrollment faster than anticipated. Required SSN collection was not a barrier to enrollment, which improved as sites became familiar with data security measures. Robust accrual to S1417CD demonstrates pts’ and cgs’ desire to improve understanding of financial toxicity and its solutions. Follow-up will conclude in 12 mo with results to follow. SWOG plans to launch a randomized study (S1912) assessing the impact of financial navigation on household finances, using credit data for primary endpoint assessment. Clinical Trials Registry Identifier NCI-2015-01885. Clinical trial information: NCT02728804.

Clinical work intensity among medical oncologists

118

Background: Oncology faces workforce shortages and increasing stress. Oncology provider well-being and resilience are mediated by organizational factors through clinical work intensity. Clinical work intensity (CWI) is the level of requisite technical skill, physical and mental effort and clinical judgement necessary, plus care provision-associated stress. Suboptimal clinical work intensity may result from unfavorable practice organizational factors preceding burnout. This pilot study assess CWI experienced by medical oncologists and oncologic advanced practice registered nurses (APRNs)/nurse practitioners as a prelude to a study of provider resilience. Methods: Investigators solicited seventeen medical oncologists-12 physicians and 5 nurse practitioners-from five oncology clinics in the Northwest, Midwest, and Southern regions of the United States Providers reported on level of work intensity associated with 339 patient visits occurring over an 8 week period where for each provider 5 visits were randomly selected from each of 4 randomly selected clinic days. Intensity was measured by the NASA-Task Load Index that assesses 6 dimensions (subscales) with additional questions measuring stress and visit satisfaction. Results: Compared to medical oncologists, APRNs reported a higher work intensity score on average (38.6 vs. 32.9; p < 0.0064), and higher scores on the frustration subscale (36.5 vs. 21.5; p < 0.0001). APRNs also scored higher on stress (27.8 vs. 22.2; p < 0.048), and scored lower on provider-perceived satisfaction with the visit (73.0 vs. 81.1; p < 0.0001). There was no difference between oncologists and nurse practitioners on the other dimensions, including mental, time, and physical demand, and effort. Conclusions: Oncologic APRNs may experience greater work intensity than medical oncologists. Future research will consider whether APRN work intensity scores reflect different or disproportionate challenges owing to scope of practice, workload, or administrative responsibilities, and determine those dimensions of higher work intensity that portend provider burnout. The goal is to identify strategies optimizing work intensity among oncology providers, mitigating provider burnout and enhancing the practice environment.

Modeling of quality of life in older adults with advanced cancer: Data from a URCC NCORP multisite trial

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Background: While the importance of symptom assessment is well recognized in Palliative Care (PC), limited evidence is available on the growing population of older adults with advanced cancer. Increasingly geriatric assessment (GA), which incorporates validated tools to assess health status, is advocated as a component of the care for older patients with cancer, but is not routinely incorporated into PC evaluations. We tested the hypothesis that variability in QoL for older adults with advanced cancer would be predicted by both symptoms and GA. Methods: Data from an ongoing cluster RCT conducted at 68 oncology practices were analyzed. Inclusion criteria were: > 70 years old, advanced solid tumor diagnosis, impairment in at least 1 GA domain (e.g., function). Multiple reliable and valid objective assessments and self-report measures for each GA domain were completed. Symptoms were assessed by MD Anderson Symptom Inventory (MDASI). Hierarchical regression modeling was conducted. The dependent variable was FACT score at Time 2 (4-6 weeks). The independent (Time 1) variables were entered in 3 steps: 1) gender, race, educational level( < or > high school), cancer type ( GI / Lung or other), receiving chemotherapy; 2) MDASI, 3) GA measures: Polypharmacy, Blessed Orientation and Memory Concentration Test, % weight loss, Short Physical Performance Battery, Instrumental Activities of Daily Living (IADL), Older Adult Resource Survey (OARS) Comorbidity, OARS Medical Social Support, and Generalized Anxiety Disorder-7. Results: N = 342 at time 1 (Mean age 77 years, 43% female, 90% white, 51% high school graduates, 49% GI or Lung cancer, 68% on chemotherapy). N = 303 at time 2(11% attrition due to death or withdrawal). Overall, 46% of variance in QoL was explained (demographic and disease characteristics: 4% [p = .05], symptoms: 32% [p < .0001], GA measures: 10% [p < .0001]). Significant individual GA predictors of worse QoL were lower social support, higher anxiety, impairment in IADLs, and poorer physical performance. Conclusions: Findings suggest that GA explains variance in quality of life scores for older adults with advanced cancer and reinforce the importance of symptom assessment and management in this population. Clinical trial information: NCT02107443.

Sexual function, quality of life, and cancer-related distress among prostate cancer survivors

e16587

Background: Prostate cancer (PC) survivors experience long-term disease consequences that can affect quality of life (QoL). This study examined QoL in key areas affected by PC and its association with cancer-related distress. Methods: Of 225 PC survivors enrolled in the Cancer Support Community’s online Cancer Experience Registry, 50 completed questions about cancer-related distress, cancer history, and the Prostate Cancer-Related QoL Scales. Results: Participant median age was 66 years; 21% had surgery, 32% underwent radiation, and 19% reported both. 31% currently and 18% previously received hormone therapy. 38% were diagnosed 5+ years ago; 26% reported recurrence, 30% reported metastatic disease. 76% reported erectile dysfunction (ED) since diagnosis. ED was more common (84%) among those who underwent surgery/radiation than those who had not (44%; chi2= 6.1, p < .05) and among those currently (100%) or previously (88%) receiving hormone therapy than those who had not (60%; chi2= 9.1, p < .05). 23% reported that incontinence made sexual activity/intimacy difficult. 20% “somewhat to very much” agreed they would choose a different treatment if they could redo their decision. QoL scores (mean±SD; scale range 0-100; higher = better QoL) were: Marital Affection (84.4±26.2); Masculine Self-Esteem (78.4±23.4); PSA Concern (77.2±21.6); Informed Decision (67.8±23.5); Urinary Control (62.1±23.6); Sexual Intimacy (59.1±34.9); Outlook (54.9±38.0); Cancer Control (49.1±31.1); and Sexual Confidence (44.1±33.7). Health Worry and Treatment Regret scores (higher = lower QoL) were 39.5±27.9 and 16.1±19.9, respectively. All QoL scales except Outlook and PSA Concern were correlated with overall cancer-related distress (r = .43 to .77; ps < .05), where lower QoL was associated with greater distress. Conclusions: Some PC survivors report substantial treatment regret, and many also endorse health concerns about uncertainty and disease progression, as well as reduced sexual confidence and intimacy. Lower perceived QoL, including sexual confidence and intimacy, is associated with greater cancer-related distress among survivors. Efforts are needed to address reduced QoL in a variety of life domains among PC survivors.

Greenville health system (GHS) experience with risk reduction endocrine therapy for women diagnosed with breast lobular carcinoma in situ (LCIS)

e13041

Background: LCIS is associated with a 1% annual risk of developing invasive breast cancer, twice that of the general population. Endocrine therapy for chemoprevention has been shown to decrease this risk by 56% in women with LCIS. Barriers include failure to offer endocrine therapy and failure to tolerate it. This study examined a population of women with LCIS and their experience with endocrine therapy for breast cancer risk reduction. Methods: 337 patients with LCIS from 2010-2015 at the GHS were retrospectively identified through electronic health record review. Median age was 55.5 years; 303 underwent breast-conserving surgery and 34 mastectomy. Chart review assessed the documented recommendations for endocrine therapy, duration of adherence, and presence of side effects. Results: Endocrine therapy was prescribed in 155 (46%), refused in 33 (10%), and not recommended in 120 (36%). Of the 146 women who were started on endocrine therapy for risk reduction and followed for six months, 75% adhered to the endocrine therapy. Of the 94 followed for 2 years, 71% adhered. The rate of documented side effects was 14% and was the most commonly cited reason for discontinuation (78%). Conclusions: The number of women with LCIS that were not prescribed endocrine therapy in the absence of absolute contraindications was substantial (36%). Under documentation in the medical record may account for a portion of this. The rate of side effects of those started on endocrine therapy (14%) is lower than expected, although this may represent underreporting. With a low refusal rate (10%) and a high adherence rates (75% at 6 months and 71% at 2 years) in the treated population, improving the number of women with LCIS that are offered endocrine therapy has considerable potential for reducing breast cancer risk. Controlling side effects can increase the benefit further.

Use of heart rate variability (HRV) biofeedback for symptom management among cancer survivors

10099

Background: Late effects of cancer and its treatment include pain, fatigue, stress, and depression all mediated by autonomic dysfunction. Heart Rate Variability (HRV) coherence is an established measure of autonomic dysfunction. Cancer survivors have lower HRV coherence than normal controls. HRV biofeedback (HRV-B) training improves HRV coherence, restores autonomic health, and reduces the above symptoms. This report describes a feasibility study of HRV-B in symptomatic cancer survivors. Methods: In a randomized, waitlist controlled, clinical trial, 179 were screened, 34 enrolled and 31 completed the protocol. Participants in the intervention arm received weekly HRV-B training up to six weeks. Outcome measures assessed at baseline (pre) and after week six (post) included HRV coherence plus Insomnia Symptom Questionnaire (ISQ), Suscro Distress Inventory (SDI), Brief Pain Inventory (BPI), Multi-Dimensional Fatigue Inventory (MFI), Perceived Stress Scale (PSS) and Beck Depression Inventory II (BDI-II). Results: See table below. Conclusions: Delivering HRV Biofeedback training to cancer survivors is feasible at our Cancer Institute. This pilot study provides preliminary evidence that HRV-B for cancer survivors improves HRV coherence and reduces insomnia, pain, fatigue, depression, and stress. The intervention has great potential and further research is indicated. [Table: see text]

Heart rate variability (HRV) training for symptom control in cancer survivors

148

Background: Late effects of cancer and its treatment include pain, fatigue, stress, and depression, all mediated by autonomic dysfunction. Heart Rate Variability (HRV) coherence is an established measure of optimal autonomic function. HRV coherence is achieved when the heart beat-to-beat intervals increase and decrease with respiration in a smooth rhythm. High coherence is associated with improved mood, cognition, executive function, and optimal pulmonary gas exchange. Cancer survivors have lower HRV than controls. Low HRV has been associated with early mortality, inflammation, and other adverse intermediary outcomes. HRV biofeedback (HRV-B) training improves HRV coherence, restores autonomic health, and reduces the above symptoms. HRV-B is non-pharmacologic, inexpensive, and self-maintained. This report describes a feasibility study of HRV-B in symptomatic cancer survivors. Methods: In a randomized, waitlist-controlled clinical trial, 179 were screened, 35 enrolled and 31 completed the protocol. Participants in the intervention arm received weekly HRV-B training up to six weeks. Outcome measures assessed at baseline (pre) and after week six (post) included HRV coherence plus the Brief Pain Inventory (BPI), Multi-Dimensional Fatigue Inventory (MFI), Perceived Stress Scale (PSS) and Beck Depression Inventory II (BDI-II). Data analyzed using linear-mixed models for repeated measures (SAS Proc Mixed). Results: Conclusions: Delivering HRV Biofeedback training to cancer survivors is feasible in a clinical setting. This study provides preliminary evidence that HRV-B training for cancer survivors improves HRV and reduces pain, fatigue, stress, and depression. HRV-B training has potential for symptom control in cancer survivors. Controlled, multisite studies are indicated.[Table: see text]

Development and implementation of an electronic measurement process for survivorship care plan dissemination and compliance

67

Background: Cancer programs must comply with survivorship care plan (SCP) delivery by 2018 to maintain or achieve Commission on Cancer (CoC) accreditation. Barriers to measuring and tracking SCP compliance include insufficient staffing to facilitate the documentation and input of data, lack of electronic medical record automation methods, lack of interoperability and electronic health record reporting processes. In June 2016, The Greenville Health System-GHS Cancer Institute Center for Integrative Oncology and Survivorship-CIOS developed a process to record, measure and track the number of SCP delivery visits delivered to Cancer Survivors. Methods: A patient who attends an SCP visit sees a provider in collaboration with a nurse navigator. The provider explains the elements within the patient’s SCP document. A copy is provided to the patient. The SCP document is embedded within the providers note for the SCP visit. To document the visit and delivery of the SCP, the nurse navigator clicks the “complete SCP visit” button located in the patient’s EMR. The SCP button also identifies the name of the provider and whether the SCP was complete or incomplete. This action in the EMR enables the creation of reports that record and document SCP delivery. Results: Four weeks were chosen during the initial implementation period to evaluate use of the SCP delivery button. For each visit provided, the SCP delivery button was clicked documenting the delivery of the SCP. The weekly data for #SCP deliveries documented and total #SCP visits are: Week 1, 17 of 22 (77%); Week 2, 16 of 17 (94%); Week 3, 13 of 13 SCP (100%); Week 4, 12 of 12 SCP (100%). Of the 64 SCP’s, 42 were complete and 22 incomplete. Conclusions: The development of the electronic measurement process for survivorship care plan delivery has significantly increased efficiency of reporting and has decreased time spent on chart audits.

Community experience with a cancer survivor smoking cessation program

182

Background: In 2014, GHS began a smoking cessation program for cancer survivors staffed by nurse practitioners and nurse navigators who are certified smoking cessation providers. The program is four scripted visits plus telephone support. Patients learn to become smoke-free by nicotine weaning and replacement, medication management, and integrative coping skills such as hypnosis. The purpose of this descriptive analysis is 1) to determine program smoking cessation rates and 2) to profile patients who completed the program successfully (nonsmoker status). Methods: Patient records from the first 12 months were mined for the following variables: demographics, primary insurance type, primary diagnosis, number of visits, number of cigarettes smoked per day at enrollment, alcohol use, and depression. Data was analyzed using Stata13. The GHS IRB approved the study. Results: Of the 143 patients referred to CIOS for smoking cessation during the first year, 70 (49%) enrolled in the program. 29 (20%) patients completed the program, and 11 (8%) others are in the process of completing the program. 23 (79%) of the 29 completers achieved non-smoker status at the time of program completion. Two months after program completion, only two nonsmoking completers reverted to smoking status. When stratifying completers by key demographic, clinical, and behavioral characteristics, the most successful were females (93% vs. 67% for males), Caucasians (82% vs. 71% for African-Americans), married individuals (100% success rate for married vs. 50% for divorced), and those with private insurance (100% vs. 79% Medicare and 67% Medicaid). Logistic regression did not reveal an increased probability of smoking cessation success with any of the key independent variables. Conclusions: This smoking cessation program using nicotine weaning and replacement, medication management, and integrative coping skills in a cancer survivor population has an encouraging success rate for those who complete the four-visit program. The relative success of married persons and females warrants further study as do the low enrollment rate of those referred, the low completion rate of those enrolled, and the continuing nonsmoking success rates for completers.

Phase II study of gemcitabine, cisplatin, and sunitinib (S) in patients with advanced urothelial carcinoma (UC)

282

Background: Sunitinib (S) has single-agent activity in patients with advanced urothelial carcinoma (UC). Preclinical studies in UC demonstrate at least additive antitumor activity combining S with gemcitabine (G) or cisplatin (C).

Methods: Patients with chemonaïve metastatic UC were enrolled in a multicenter phase II trial with overall response rate (ORR) as the primary endpoint. The initial dosing regimen, based on a phase I trial (Reck, 2010), was G 1000 mg/m2 IV (Days 1 & 8), C 70 mg/m2 IV (Day 1), and S 37.5 mg PO daily (Days 1-14)/each 21-day cycle (up to 6 cycles), followed by S 37.5 mg daily until progression.

Results: From December 2008 to August 2009, 15 eligible patients enrolled. Seven of 15 patients discontinued treatment early (median: 3 cycles) due to toxicity, most often due to recurrent neutropenia and thrombocytopenia. Intrapatient dose reductions were required for G (12/15), C (8/15), and S (10/15). Eight of 15 patients experienced serious adverse events. Based on the toxicity profile, enrollment was held and the dosing regimen was revised to G 800 mg/m2 IV (Days 1 and 8), C 60 mg/m2 IV (Day 1), S 37.5 mg PO daily (Days 1-14). From December 2009 to April 2011, 18 additional patients were enrolled. Despite the reduced starting doses, intrapatient dose reductions were required for G (13/18), C (9/18), and S (15/18). The most frequent Grade 3-4 toxicities for both groups were neutropenia (70%), thrombocytopenia (58%), and anemia (30%). Antitumor activity is shown in the Table. Median PFS was 7.9 and median OS was 13.8 months.

Conclusions: Combination G+C+S is poorly tolerated and results in activity comparable to historical results with G+C alone. Supported in part by a grant from Pfizer Inc.

[Table: see text]

Reduction of beta-endorphin content in the rat pituitary after dehydration and adrenalectomy

Both dehydration and adrenalectomy of rats caused a significant reduction of immunoreactive beta-endorphin in the pituitary gland. Beta-Endorphin in hypothalamus, however, was not altered in either dehydrated or adrenalectomized rats.

Multicenter phase II study to evaluate a 28-day regimen of oral fluorouracil plus eniluracil in the treatment of patients with previously untreated metastatic colorectal cancer

PURPOSE

To determine the efficacy of fluorouracil (5-FU) plus eniluracil when administered to patients with previously untreated metastatic colorectal cancer.

PATIENTS AND METHODS

In this single-arm phase II study, patients with previously untreated metastatic colorectal cancer received oral eniluracil plus 5-FU (10:1 dose ratio), at 5-FU doses of 1.00 mg/m(2) or 1.15 mg/m(2) twice daily (every 12 hours) for 28 consecutive days repeated every 5 weeks (one cycle). Treatment continued until there was documented disease progression or unacceptable toxicity.

RESULTS

Thirty and 25 patients were enrolled at a starting dose of 1.00 mg/m(2) and 1.15 mg/m(2), respectively. Fourteen (25%) of 55 patients (95% confidence interval, 15% to 39%) had a partial response, and 20 patients (36%) had stable disease. The median durations of the partial responses and stable disease were 23.9 weeks (range, 12.3 to 52.1+ weeks) and 24.1 weeks (range, 17.1 to 55.6+ weeks), respectively. The median durations of progression-free and overall survival were 22.6 weeks (range, 21.0 to 29.0 weeks) and 59 weeks (range, 4 to 84+ weeks), respectively. The response rate in the 1.15 mg/m(2)-dose group was similar to the 1.00 mg/m(2)-dose group (28% v 23%, respectively). Severe (grade 3/4) nonhematologic treatment-related toxicity included diarrhea (nine patients), nausea/vomiting (one patient each), mucositis (two patients), and anorexia (one patient). Severe hematologic toxicities were rare. At the 1.15 mg/m(2)-dose level, two patients exhibited grade 3 granulocytopenia, and two patients had grade 3 anemia.

CONCLUSION

The response rate with oral 5-FU plus eniluracil is comparable with that observed with infusional 5-FU or bolus 5-FU and leucovorin. The toxicity profile of this oral regimen is acceptable for use in an outpatient home-based setting.

A phase II study of 9-aminocamptothecin in patients with refractory breast cancer

We evaluated 9-aminocamptothecin (9-AC) in patients with metastatic or locally recurrent breast cancer who were no longer responsive to standard therapy. Patients were treated with 9-AC with a 72-hr continuous infusion given at a dose of 45 micrograms/m2/hr every 2 weeks. Granulocyte colony-stimulating factor 5 micrograms/kg was given subcutaneously for 7-10 days after completion of the treatment. Eighteen patients were treated, with all patients assessable for toxicity and 15 patients assessable for response. There were two partial responses seen in the 15 patients lasting 3.5 and 5 months, respectively. The major toxicity seen was myelosuppression, with 12 patients having grade 3 or greater granulocytopenia with four episodes of significant infectious complications. In addition, significant thrombocytopenia was seen in 14 patients. The other complications commonly seen were nausea and vomiting and alopecia. 9-AC given as a 3-day continuous infusion has limited activity in previously treated metastatic and locally recurrent breast cancer.

Phase II trial to topotecan in hepatocellular carcinoma: a Southwest Oncology Group study

Hepatocellular carcinoma remains a highly chemoresistant neoplasm. In this study of the topoisomerase I inhibitor topotecan a response rate of 13.9% (95% confidence interval 4.7%-29.5%) was obtained utilizing a five consecutive day bolus infusion schedule. There were no complete responses and the median survival was only eight months. Furthermore, treatment with topotecan produced significant toxicity with two-thirds of patients experiencing life-threatening (grade 4) neutropenia. When used in this dose and schedule, topotecan does not appear to be effective for patients with advanced hepatocellular carcinoma.

Phase II evaluation of ifosfamide/mesna in metastatic prostate cancer. A Southwest Oncology Group study

The combination of ifosfamide and mesna was evaluated in a phase II trial in the treatment of metastatic prostate cancer. Two separate groups of patients were to be evaluated: patients with no prior hormonal therapy and hormonally refractory patients. Patients were treated with ifosfamide 1.5 g/M2, and mesna at 30% of the ifosfamide dose was administered immediately before and 4 and 8 h after ifosfamide treatment. Both drugs were given i.v. daily for 5 days every 21 days. Response was assessed every 6 weeks. Of 29 eligible and evaluable patients with hormonally refractory disease, there were two partial responders for a response rate of 7% (95% confidence interval, of 0.1-23%). Of nine eligible patients with no prior hormone treatment, there was one partial response, for a response rate of 11% (95% confidence interval, 0.3-48%). Unfortunately, the target accrual goal for this arm of the study was never achieved. The most common toxicities were myelosuppression and neurologic toxicity. These drugs do not warrant further evaluation in the disease.

Vinorelbine (Navelbine)/carboplatin combination therapy: dose intensification with granulocyte colony-stimulating factor

Treatment with platinum agents or the new vinca alkaloid vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Médicament, Paris, France) results in prolonged survival in patients with advanced non-small cell lung cancer (NSCLC). To determine whether a unique combination of these agents might enhance activity against NSCLC, a combination chemotherapy regimen consisting of intravenous carboplatin, administered on days 1 and 29, and intravenous vinorelbine, given once weekly, was evaluated. Because the dose-limiting toxicity of both agents is myelosuppression, an additional study goal was to assess the ability of granulocyte colony-stimulating factor to alleviate hematologic toxicity and allow on-time, full-dose vinorelbine therapy. To this end, a phase I/II study was begun. Phase I of the study included 22 patients (15 men and seven women) with a median age of 63 years (age range, 39 to 77 years) who had stage IV NSCLC and no prior chemotherapy. Phase I consisted of 28-day cycles in which intravenous carboplatin was administered at an area under the curve of 7 by the Calvert formula, dose range 350 to 450 mg/m2, and intravenous vinorelbine was administered weekly. Granulocyte colony-stimulating factor was administered if dose-limiting neutropenia developed. Four cohorts of patients were studied, ranging from those who received no vinorelbine to those who received drug doses of up to 30 mg/m2. Patients were able to tolerate the highest dose of vinorelbine, but the majority required granulocyte colony-stimulating factor support to do so. No novel toxicities were observed in patients treated with the combination of carboplatin and vinorelbine.(ABSTRACT TRUNCATED AT 250 WORDS)

Tamoxifen versus high-dose oral medroxyprogesterone acetate as initial endocrine therapy for patients with metastatic breast cancer: a Piedmont Oncology Association study

PURPOSE

To determine in a prospective randomized trial whether high-dose orally administered medroxy-progesterone acetate (MPA) was superior to tamoxifen in patients with recurrent or metastatic breast cancer who had received no prior endocrine therapy in either the adjuvant or advanced setting.

PATIENTS AND METHODS

Patients initially received either tamoxifen 20 mg/d orally or MPA 1 g/d orally. At the time of disease progression, patients were crossed over to the other regimen. Eligibility required patients to be age > or = 18 years, performance status 0 to 3, and estrogen receptor (ER)- or progesterone receptor (PR)-positive or unknown.

RESULTS

One hundred eighty-two eligible patients were entered and 166 were assessable for response. Complete plus partial response rates for tamoxifen and MPA were 17% and 34%, respectively (P = .01). Patients with bone metastases had a significantly higher partial response rate with MPA compared with tamoxifen (33% v 13%). Median time to treatment failure was 5.5 months for tamoxifen and 6.3 months for MPA (P = .48). The median survival duration was 24 months for tamoxifen and 33 months for MPA (P = .09). Multivariate analysis showed that treatment significantly influenced response rate, but not time to treatment failure or survival. After treatment failure following MPA, six of 42 patients (14%) treated with tamoxifen responded, compared with six of 49 (12%) treated with MPA following tamoxifen. Both agents were associated with minimal toxicity, but 35% of patients on MPA gained more than 20 lb as opposed to only 2% on tamoxifen.

CONCLUSION

In this trial, initial treatment with MPA of endocrine-naive metastatic breast cancer patients was associated with a significantly higher response rate but not with improvement in time to treatment failure or survival, when compared with initial treatment with tamoxifen. Further randomized trials in patients with bone metastases are warranted to determine if high-dose progestin therapy is superior to tamoxifen in these patients.

Lung cancer in the elderly

Half of all lung cancers occur in persons aged 65 years and older. The symptoms of lung cancer in the elderly may be nonspecific and misleading. Age trends in incidence, histologic subtype, and stage suggest that selective screening of older persons for lung cancer should be studied. Recent data reveal that the mortality risk for lung cancer surgery in selected elderly patients is comparable to that for younger patients. Age alone should not deny older lung cancer patients optimal evaluation, treatment, and care.

Age trends of lung cancer stage at diagnosis. Implications for lung cancer screening in the elderly

Lung cancer increases in incidence with increasing age and is the leading cause of cancer death in the United States. While mass screening for lung cancer is not indicated, selective screening of high-risk target groups may be beneficial. We tested the hypothesis that lung cancer is initially seen at a less advanced stage with increasing age using incidence cases (N = 22,874) from the Centralized Cancer Patient Data System. The percent of lung cancer patients with local stage disease increased from 15.3% of those aged 54 years or younger, to 19.2% of those aged 55 to 64 years, to 21.9% of those aged 65 to 74 years, and to 25.4% of those aged 75 years or older. The percent with distant stage decreased from 48.7%, to 44.5%, to 40.3%, and to 36.7% for the same age groups, respectively. These age-stage trends persisted in subgroup analysis by sex, race, and histological subtype. Furthermore, analysis of 6332 patients who underwent surgical staging showed a greater likelihood of local stage disease with increasing age. Thus, compared with the young, the group aged 65 years or older is at a greater risk for lung cancer and has a higher proportion of lung cancer initially seen at local stage. The efficacy of selective screening for lung cancer in this target group warrants additional study.

Potentiation of opiate action in neuroblastoma N18TG2 cells by lipid incorporation

The effect of cerebroside sulfate, phosphatidylserine, and other phospholipids on opiate receptor function in neuroblastoma N18TG2 cells was studied by incorporation of lipids into the membrane bilayer of viable cells. A concentration- and time-dependent incorporation of sulfatide by N18TG2 cells was observed. The incorporated lipid was not metabolized during the incubation period of up to 48 hr at 37 degrees. Optimal conditions for lipid incorporation were determined to be 4 days after the cell seeding and in 1% fetal calf serum. The incorporated lipid was established to be associated with the plasma membrane fraction of the crude cell homogenate. Furthermore, increases in Vmax but not Km values of the adenylate cyclase for Mg2+, ATP, and prostaglandin E1 were observed in neuroblastoma N18TG2 cells exposed to cerebroside sulfate for 4--6 hr. The incorporation of cerebroside sulfate or phosphatidylserine by N18TG2 cells did not increase the number of opiate binding sites in this cell line as determined by [3H]naloxone, [3H]etorphine, or 3H-labeled D-Ala2-Met5-enkephalinamide binding. Although there was an increase in the affinity of [3H]naloxone binding, linear correlation between the amount of cerebroside sulfate incorporated and the quantity of binding increase was not observed. However, augmentation of both the potencies and the efficacies (maximal inhibitory level) of morphine and enkephalin to regulate adenylate cyclase activity was observed after sulfatide incorporation. At the maximal concentration of cerebroside sulfate used (67 microM) the opiate receptor activity in N18TG2 cells approached that of NG108-15 cells. Identical treatment of N18TG2 cells with cerebroside or psychosine sulfate did not produce any potentiation of the opiate inhibition of adenylate cyclase. Of all of the phospholipids tested--phosphatidylserine, phosphatidylinositol, and phosphatidylcholine--only phosphatidylcholine produced a potentiation of the opiate effect. Both synthetic dipalmitoyl phosphatidylcholine or brain phosphatidylcholine could elicit the potentiation.